Travel Risk Assessment

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment.

Please be aware there is currently a national shortage of many travel vaccines and in particular Hepatitis A and B. We will endeavour to provide the immunisations you need but our ability to do so may be affected by these shortages.

You must be a registered patient at The Waterfield Practice to receive travel advice from us.

Travel Risk Assessment

Please note: You must be a registered patient at The Waterfield Practice to receive travel advice from us.
Please use this date format: DD/MM/YYYY.

We will only use this email address for correspondence in relation to this request and will not sell it onto third parties.

Please use this date format: DD/MM/YYYY
Please use this date format: DD/MM/YYYY
Please write your name. For discussion when risk assessment is performed within your appointment. I have no reason to think that I might be pregnant. I have received information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to the vaccines being given.

For Practice use only

Authorisation for a Patient Specific Direction (PSD)

Tetanus/polio/diptheria    MMR    Influenza   
Typhoid    Hepatitis A    Pneumococcal   
Cholera    Hepatitis B    Meningitis   
Rabies    Japanese Encephalitis    Tick Borne Encephalitis   
Yellow Fever    BCG    Other   
Malaria Tablets   

Following the completion of a travel risk assessment, the below named vaccines may be administered under this PSD to:

Name Date of birth
     

Name, form & strength of medicine (generic/brand name as appropriate) Dose, schedule and route of administration Start and finish dates
        
        
        
        
        

Signature of Prescriber Date